CERVICAL MYELOPATHY

dr. Aries Rahman Hakim

Natural History
• Degenerative changes at the cervical discs and facet joints are common
in the adult population; these changes are a natural consequence of
aging and are asymptomatic in most of the population.
• Spondylosis refers to these age-related degenerative changes within the
spinal column. Most patients who present with cervical spondylosis are
older than 40 years.
• Although most of these age-related degenerative changes remain
asymptomatic, they can manifest as three main symptom complexes—
axial neck pain, upper extremity radiculopathy, or myelopathy—or some
combination thereof.
Cervical Spondylosis :
• 1: Axial neck pain = refers to pain along the spinal column and its
related paraspinal musculature.
• 2: Cervical radiculopathy = pain radiating into the arm, which may be
accompanied by sensoric or motoric changes in a radicular
distribution.
• 3: Cervical myelopathy = the development of long tract signs as a
result of degenerative changes at the cervical spinal motion segment
Cervical Myelopathy
• Primary pathophysiologic mechanism: mechanical compression of the spinal cord

• But, in many patients, a combination of static compression combined with dynamic factors
secondary to motion between the vertebral bodies, a congenitally stenotic canal, changes in the
intrinsic morphology of the spinal cord, and vascular factors also contributes to the development
of myelopathy.
Pathophysiology
• A developmentally narrow spinal canal in the anteroposterior
plane can contribute to the development of cervical
myelopathy.
• The normal anteroposterior diameter of the cervical spine
measures 17 to 18 mm in adults, and the anteroposterior
diameter of the spinal cord in the cervical region measures
approximately 10 mm.
• An anteroposterior diameter of the spinal canal less than 13
mm defines congenital cervical stenosis, whereas a diameter
greater than 16 mm suggests a relatively low risk of
myelopathy
• A congenitally narrow spinal canal lowers the threshold at
which the cumulative effects of various degenerative structures
encroaching on the spinal cord cause signs and symptoms of
myelopathy
Clinical Finding
• The physical findings in cervical spondylotic myelopathy can vary significantly depending on the anatomic
portion of the cord primarily involved.

• Sensory symptoms arise from compression at three discrete anatomic locations:

• (1) the spinothalamic tract, affecting contralateral pain and temperature sensation with light touch often
preserved;
• (2) posterior columns, affecting ipsilateral position and vibration sense, possibly leading to gait
disturbances
• (3) dorsal root compression, leading to decreased dermatomal sensation.

• The motor and reflex examination typically reveals lower motor neuron signs at the levels of the cervical
lesions (hyporeflexia and weakness in the upper extremities) and upper motor neuron signs below the lesions
(hyperreflexia and spasticity in the lower extremities).
Clinical Finding
• There is no pathognemonic signs and symptoms for myelopathy
• Diagnosis established by affirmation of
clinical presentation with radiographical findings

Early Findings Late Findings

Disdiadochokinesia Spasticity
Difficulty with tandem gait Difficulty with routine gait
Fine motor deficits Gross motor deficits
Mildly increased reflexes Markedly increased reflexes
Clonus (mild and unsustained) Clonus (sustained)
Decreased proprioception Gross difficulty with balancing
Physical Examination
• Patients with moderate to severe spondylotic myelopathy
typically exhibit the following pathologic reflexes to
varying degrees:
• (1) the inverted radial reflex—indicative of cord
compression at C6 and present when, during elicitation of
a brachioradialis reflex, the brachioradialis is
hyporesponsive and the ipsilateral fingers flex briskly at
each hammer tap;
• (2)the Hoffman reflex—present if the ipsilateral
interphalangeal joints of the thumb and index finger flex
when the volar surface of the distal phalanx of the long
finger is flicked into extension and strongly indicative of
cord impingement when asymmetric;
• (3) the extensor plantar reflex (also called the
Babinski sign)—present when rubbing of the lateral sole
of the foot from the heel along a curve to the metatarsal
pads with a blunt object causes the hallux to dorsiflex and
the lesser toes to fan out
Physical Examination

Pathological Reflexes
Hoffman sign
Babinski sign
Lhermitte sign
Physical Examination
• The findings in cervical spondylotic myelopathy vary with each
patient.
• Patients may report an insidious onset of clumsiness in the hands or
diffuse numbness in the hands resulting in worsening of handwriting
or other fine motor skills over the past few months or weeks and
difficulty with grasping or holding objects (i.e., trouble with
manipulating buttons or zippers).
• Patients frequently experience increasing difficulty with balance that
they attribute to age or arthritic hips; relatives may note that the
patient’s gait has become increasingly clumsy, that the patient holds
onto objects to help with balance, and that he or she sustains
occasional falls 
CERVICAL SPONDYLOTIC
MYELOPATHY
Nurick’s Functional Scale
Classification System of CSM

Japanese Orthopaedic
Association (JOA) score

Operative treatment provides excellent

results for patients with severe clinical
presentation (JOA score ≤7),

while individuals with mild to moderate

spinal stenosis (JOA score >7) should
receive conservative treatment.
Diagnostic – Plain Radiograph
• Radiographic evaluation usually begins
with plain radiographs; lateral,
anteroposterior, and oblique views are
obtained. Global and segmental
alignment can be easily assessed.
• Findings of degenerative disease
include disc space Narrowing of the disc
space, bone spurs, osteophytes, joint
subluxation, facet joint arthrosis,
spondylolisthesis, and OPLL may be
visualized.
Diagnostic – Plain Radiograph
• Foraminal stenosis may occur from
uncovertebral arthrosis or
degenerative subluxation. Typically,
bony elements are visualized, but
radiographs inherently are unable
to assess neural elements. An
indirect assessment of the neural
foramina can be obtained with
oblique views.
• To evaluater can be obtained with
Dynamic Photo Flexion and
Extension
Diagnostic – Plain Radiograph
• Although the soft tissue component of spinal cord compression
cannot be visualized on lateral radiographs, the space available is
easily assessed. Brain and Wilkinson2 reported an average space of 17
to 18 mm (range 14 to 23 mm). 
Diagnostic – CT Scan
• Visualize osteophytes and
stenosis of vertebral
foramina.
• CT myelography
(improved imaging of soft
tissues and foraminal
stenosis) is useful when
MRI is contraindicated.
Diagnostic – MRI
• More sensitive to changes of
disc, spinal cord, nerve root and
surrounding soft tissues
Diagnostic – Electodiagnostic Studies
• Electrodiagnostic studies are another diagnostic modality used to
evaluate patients with radiculopathy.
• Peripheral nerve root entrapment can mimic cervical radiculopathy.
Currently, electromyography (EMG) is the most useful modality.
• In some studies, 75% sensitivity has been reported. Because of the
variable sensitivity of EMG, it is not an ideal screening tool. 
Diagnostic – Electodiagnostic Studies
• The diagnosis and location of pathology can be assessed with EMG,
however. Compression causes pathophysiologic changes within the
nerve root. These changes are shown on EMG as decreased motor
unit potentials and fibrillation potentials. 
• When the diagnosis is clear from imaging and clinical examination,
EMG is probably unnecessary. EMG and nerve conduction studies may
be beneficial to distinguish specific nerve root compression when
multilevel disease is present. 
Differential Diagnose
• Many neurologic conditions resemble cervical spondylotic
myelopathy.
• Multiple sclerosis has distinctive plaques that can be seen on
magnetic resonance imaging (MRI) of the brain and spinal cord.
The disease is a demyelinating disorder of the central nervous
system and causes motor and sensory symptoms but typically has
remissions and exacerbations and involvement of the cranial
nerves.
• Amyotrophic lateral sclerosis results in upper and lower motor
neuron symptoms, without alteration in sensation.
• Subacute combined degeneration seen with vitamin B12
deficiency causes corticospinal tract and posterior tract
symptoms, with greater sensory involvement in the lower
extremities.
• Patients with metabolic or idiopathic peripheral neuropathy have
sensory symptoms that may mirror symptoms of myelopathy
Treatment
Conservative Treatment Operative Treatment

• Response in days to • Indicated in:

weeks – Evidence of compression
• Protracted non-op care of nerve root or spinal cord
not recommended in – Instability
presence of: – Deformity
– Persistent, severe pain – Failed conservative tx
– Weakness – Significant neurologic
– Major sensibility loss deficit
– Myelopathy with obvious – Severe myelopathy
cord findings
Non Operative Treatment
One series of cervical radiculopathy reported that 20 of 26 (77%)
patients had good to excellent results with a progressive program of
nonoperative treatment consisting of immobilization, ice, rest,
nonsteroidal anti-inflammatory drugs [NSAIDs], traction, postural
education and strengthening, oral steroid tapers, acupuncture, and
transcutaneous electrical nerve stimulation
Operative Treatment
• The goals of operative intervention include decompression of the
spinal cord, stabilization of the spinal column, and reestablishment of
the normal sagittal alignment.
Surgical Indications
• The most commonly accepted indications are :
(1) persistent or recurrent arm pain that is unresponsive to a trial of
conservative treatment (3 months).
(2) progressive neurologic deficit
(3) static neurologic deficit associated with significant radicular pain,
and
(4) confirmatory imaging studies consistent with the patient’s clinical
findings 
ANTERIOR APPROACH
The spinal cord can be compressed by herniated discs, spondylotic bars,
and uncovertebral osteophytes. Direct decom-pression of the cord and
nerve roots from these degenerative changes can be accomplished with
an anterior approach.

The sagittal alignment of the spinal column is an important factor when

deciding on an anterior versus a posterior approach. Cervical kyphosis
and degenerative instability are clear indications for an anterior
approach.
ACDF (Anterior Decompression and
Fusion)
Indications :
• Maintstay of treatment in most patients with single or two level
diseases
ACCF (Anterior Corpectomy and Fusion)
Indications :
• Extensive retrovertebral disease
• Cervical kyphosis preventing from adequate decompression
posteriorly
ANTERIOR APPROACH
ANTERIOR APPROACH
POSTERIOR APPROACH
Laminectomy with Posterior Fusion
Indications :
• Multilevel compression with kyphosis of <10 degress
• > 13 degress of fixed kyphosis is a contraindications for posterior
procedure
• In flexible kyphotic spine, posterior decompression and fusion may be
indicated if kyphotic deformity can be corrected prior to
instrumentation
Laminoplasty
Indications :
• Gaining in popularity
• Useful when maintaining motion is desired
• Avoid complications of fusion so may be indicated in patient at high
risk of pseudoarthrosis
Combined Anterior and Posterior Surgery
Indications :
• Multilevel stenosis in the rigid kyphotic spine
• Multilevel anterior cervical corpectomies
• Postlaminectomy kyphosis
LAMINECTOMY & LAMINECTOMY and
FUSION
POSTERIOR – OPEN-DOOR
LAMINOPLASTY
POSTERIOR – OPEN DOOR
LAMINOPLASTY
 COMPARISON OUTCOME
Whether anterior or posterior, the appropriate approach for the treatment of CSM
depends on a host of factors, including site of cord compression, sagittal alignment,
and number of vertebral segments involved.
• Riew and colleagues reported their experience in treating postlaminectomy patients with ACCF and postoperative
halo immobilization. They showed early graft-related complica-tions in 56% of 16 postlaminectomy patients,
including graft extrusion and nonunion.
• Kim and Alexander described 35 combined anterior-posterior stabilization procedures performed at their
institution over 5 years. They observed no graft-related or instrumentation-related complications, and they did not
observe any development of nonunion.
• Shultz and colleagues reported a 100% fusion rate in 72 patients who underwent single-stage multilevel anterior-
posterior decom-pression and fusion. None of their patients required a reopera-tion, and there was no evidence
of graft extrusion or clinically significant hardware complications.
• pivak and colleagues observed that performing a com-bined anterior-posterior spinal fusion in a single setting
resulted in decreased anesthesia, decreased operative times, decreased total blood loss, and an overall shorter
hospital stay compared with a two-stage anterior-posterior fusion proce-dure.
 SUMMARY
The natural history of CSM is one of periods of static disability with episodic
worsening of symptoms. Patients with severe symptoms benefit from operative
management. Myriad options exist for the surgical treatment of multilevel CSM.
The choice of procedure should be tailored to the unique clinical and anatomic,
patient-specific characteristics in each individual case. No matter which operative
procedure is chosen, the surgeon’s primary goal should be to halt the further
progression of the myelopathy by decompressing the spinal cord and by preserving
the sagittal balance of the spinal column. The surgeon must have knowledge and an
intimate understanding of each procedure and its limita-tions when discussing
treatment options with patients. It is imperative that research be continued in the
study of CSM and in the development of newer techniques. As advances in
technology continue, surgeons will be better able to offer patients safer, more
effective surgical options in the treatment of CSM.
Refference
• Harry et al. 2011. Rothman-Simeone The Spine 6th edition.
THANK YOU